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Maureen M. Corcoran, President, Vorys Health Care Advisors

Health Care Reform Update: Beginning of the End? Or Are We Just Getting Started? The New York State Association of Community and Residential Agencies. Maureen M. Corcoran, President, Vorys Health Care Advisors Daphne K. Saneholtz, Senior Advisor, Vorys Health Care Advisors November 2013.

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Maureen M. Corcoran, President, Vorys Health Care Advisors

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  1. Health Care Reform Update: Beginning of the End? Or Are We Just Getting Started? The New York State Association of Community and Residential Agencies Maureen M. Corcoran, President, Vorys Health Care Advisors Daphne K. Saneholtz, Senior Advisor, Vorys Health Care Advisors November 2013

  2. Agenda • Environment • Health care coverage provisions of ACA • Individual mandate • Health insurance marketplaces • Essential Health Benefits • Medicaid expansion • Employer responsibilities

  3. Environment • SCOTUS decision made Medicaid expansion optional, upheld the rest of the law • Open enrollment in the marketplace began 10/1/13 • Movement to defund ACA • HealthCare.gov and state-based marketplace websites (like New York State of Health)

  4. Health Care Coverage Provisions • Review of basic health care coverage provisions • Individual mandate • Health insurance marketplaces • Requirements for “essential health benefits” • Expanding publicly funded programs, Medicaid expansion • Employer responsibilities

  5. American Health Care – A Look at Ohio Reshaping the American Economy

  6. Review

  7. Review

  8. The Affordable Care Act • Includes sweeping coverage expansions • Individual mandate – most individuals must have health insurance beginning 1/1/14 • Medicaid expansion – states must expand Medicaid to certain adults earning up to 138% FPL • SCOTUS effectively made this mandate optional • Employer mandate – large employers must offer affordable health insurance to employees • Postponed until 2015

  9. Individual Mandate • Requires that most Americans have health insurance beginning in 2014 • An individual can satisfy the mandate by: • Having employer-sponsored insurance • Buying a plan in the health insurance marketplace • Being insured through a government program • 80% of Americans will be unaffected because they already have insurance (through an employer, Medicaid, Medicare, Tricare, etc.)

  10. President’s Recent Announcement About Canceled Insurance Policies • Individuals receiving cancellation notices • One year delay for “noncompliant” plans for individual/family and small businesses that purchased policies directly from insurers • Consumers covered by Medicaid, Medicare, or large employers are unaffected. • Qualified health plans sold in the Marketplace must continue to cover EHBs, so they are unaffected.

  11. President’s Announcement (contd.) • What will happen to noncompliant plans? • They can be extended for one more year for current customers. • Policies renewing before the end of this year will last until late 2014; policies that expire in 2014 can extend into 2015. • If carriers do renew, they must disclose to the policyholder differences between the benefits offered in their existing plan and those required by the ACA.

  12. President’s Announcement (contd.) • Noncompliant plans may not be available, even given the one year delay announcement • Some states (e.g., WA), have already announced that they will not allow such renewals. Other states (e.g., FL) have announced that they will. • Also, an insurance company is not required to renew its noncompliant policy. • Remember: consumers purchasing through the Marketplace may be eligible for subsidies and/or tax credits.

  13. Health Insurance Marketplace • The ACA requires that states have health insurance marketplaces where “qualified health plans” are sold • States can implement and operate the marketplace themselves or in partnership with the federal government, or the federal government can do it • New York is operating its own marketplace – New York State of Health

  14. Health Insurance Marketplace (contd.) • Qualified health plans (QHPs) will be sold at four metal level categories that reflect the portion of medical expenses covered by the plan for the consumer • Bronze = 60%, silver = 70%, gold = 80%, platinum = 90%

  15. Health Insurance Marketplace (contd.) • Individuals earning between 100% and 400% FPL ($23,550 to $94,200 for a family of four) will have access to premium tax credits. • Individuals earning between 100% and 250% FPL ($23,550 and $58,875 for a family of four) will have access to cost-sharing subsidies.

  16. Premium Assistance for Parents in New York • Beginning January 1, 2014, New York State will pay the premium on behalf of all parents with income 138-150% FPL who enroll in QHPs through the marketplace. • Individuals must enroll in a silver level plan to be eligible for the premium assistance. • Until December 31, 2013, parents at these income levels are eligible for Family Health Plus coverage (a Medicaid expansion program), but beginning in January 2014, they will be eligible to enroll in Marketplace coverage. • Family Health Plus offers a commercial-like benefits package with no premium and modest copayments. Source: New York State of Health

  17. New York’s Marketplace • New York is 1 of 16 states operating a state based Marketplace • New York State of Health • https://nystateofhealth.ny.gov/ • 855-355-5777

  18. New York State of Health • Today nearly 2.7 million New Yorkers (about 16%) under age 65 do not have health insurance coverage. • Over 1 million New Yorkers will get health coverage through the Marketplace. • This includes 615,000 individuals and 450,000 small business employees. Source: New York State of Health

  19. Select Enrollee Demographics

  20. New York State of Health (contd.) • As of November 12, 2013, 48,162 New Yorkers have signed up for coverage through NY State of Health. • Does not include small business portion of marketplace. • Another 197,000 have been approved for coverage through the marketplace but still must select a plan; enrollment expected to pick up as we near 12/15 deadline to enroll in a plan that will take effect 1/1/14 Source: The Buffalo News. Enrollment in New York Insurance Exchange Meets Expectations. Watson, Stephen T. November 12, 2013.

  21. New York State of Health (contd.) • Of the 48,162 New Yorkers who have enrolled, 23,653 are eligible for Medicaid, either because of the Medicaid expansion included in the ACA or because they were eligible all along but weren’t enrolled. • Other New York enrollees include people who: • Previously had insurance through the state-subsidized Healthy New York program, which ends Dec. 31; • Had costly, direct-pay individual insurance; or • Had insurance that is being terminated because it doesn’t meet the ACA’s EHBs Source: The Buffalo News. Enrollment in New York Insurance Exchange Meets Expectations. Watson, Stephen T. November 12, 2013.

  22. New York State of Health: Snapshot • Independent Health (one of the insurers offering QHPs in NY) reports: • 1/3 of its enrollees are switching over from an existing Independent Health plan; • 1/3 aren’t currently insured through Independent Health but were at one time; • 1/3 have no history with the company. Source: The Buffalo News. Enrollment in New York Insurance Exchange Meets Expectations. Watson, Stephen T. November 12, 2013.

  23. New York State of Health – What will it do? • One portal will process applications for: • Medicaid • Child Health Plus • Individual Marketplace • Small Business Marketplace

  24. New York State of Health

  25. New affordable and comprehensive health insurance options will be available for New Yorkers. • Open enrollment begins October 1, 2013 for coverage that begins January 1, 2014. • If you earn less than $45,960 as an individual or $94,200 for a family of 4 you may be eligible for financial assistance that will make coverage more affordable. • You will not be denied health insurance or charged more on the basis of a pre-existing condition. • All health insurance options will offer a comprehensive array of services. • Preventive services will be offered at no cost to you. • You can get help enrolling in coverage: In-person, By phone , On-line via web chat • You pick the plan that is best for you. • Compare your plan choices

  26. Why it is now easier to pay for health insurance

  27. Tax Credit Estimator

  28. Premium Rate Estimator

  29. *Exact rates will depend on the metal tier, health plan selected, and county.

  30. *Exact rates will depend on the metal tier, health plan selected, and county.

  31. Marketplace Enrollment Source: U. S. Department of Health and Human Services. The Washington Post. November 13, 2013.

  32. Federal Marketplace Experience As of November 13 • Submitted completed applications: 1,509,883 • Eligible to enroll in a plan: 1,081,592 • Selected a plan: 106,185 Source: U. S. Department of Health and Human Services. The Washington Post. November 13, 2013.

  33. Important Insurance Deadlines • Enroll by 12/15/13 to be covered beginning 1/1/14 • Enroll by 3/31/14 to avoid tax penalties

  34. Essential Health Benefits • Beginning in 2014, Medicaid plans and small group and individual plans sold inside and outside of health insurance marketplaces must cover a package of 10 categories of items and services known as Essential Health Benefits (EHBs).

  35. What services must EHBs cover? • Ambulatory patient services. • Emergency services. • Hospitalization. • Maternity and newborn care. • Mental and/or substance use disorder services, including treatment of behavioral disorders.

  36. What Services Must EHBs Cover? (contd.) • Prescription drugs. • Rehabilitative and habilitative services and devices. • Laboratory services. • Preventive and wellness services and chronic disease management. • Pediatric services, including oral and vision care.

  37. What Will EHBs Look Like? • Defined by a benchmark plan selected by each state. • Reflects the scope of services offered by a “typical employer plan” in the state. • In New York…

  38. A Note on Hab Services • States have the option to define hab benefits in state EHBs, require parity between hab and rehab, or allow issuers to decide coverage and report to the U. S. Department of Health and Human Services.

  39. NY’s Definition of Hab Services

  40. Hab Services Under Arkansas’ EHBs • Arkansas’ proposed definition of hab services • “Subject to permissible terms, conditions, exclusions and limitations, health benefit plans, when required to provide essential health benefits, shall provide coverage for physical, occupational and speech therapies, developmental services and durable medical equipment for developmental delay, developmental disability, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder.”

  41. Medicaid Expansion Basics • The ACA expanded Medicaid eligibility to nonelderly, non-pregnant adults with income at or below 138% FPL ($32,499 for a family of four) who are not otherwise eligible for a mandatory Medicaid eligibility category or enrolled in or eligible for Medicare. • SCOTUS subsequently essentially made this mandate optional for states. • The federal government will pay 100% of the cost for the expansion population at first, ratcheting down to 90% in later years – never dropping below 90% federal financial support.

  42. Other Medicaid Basics • Requires states to implement streamlined, automated enrollment process • Includes requirements for electronic verification • Goal to have a single process for all public and commercial insurance • Implement income counting rules for Modified Adjusted Gross Income (MAGI) groups and convert existing eligibility groups

  43. Medicaid ExpansionNational Landscape As of 10/22/13Source: Henry J. Kaiser Family Foundation

  44. Without Medicaid Expansion

  45. New York and Medicaid Expansion and Eligibility • New York will expand Medicaid in 2014; it previously covered childless adults up to 100% FPL and parents up to 150% FPL • Medicaid enrollment is projected to increase by about 513,000 in total, 76,000 of whom are newly eligible enrollees • The state will end up paying less for these people • Medicaid applicants divided into two major groups: • Eligibility based on MAGI • Non-MAGI • Includes SSI-related groups (age 65 and up, disabled, or blind), those utilizing spend down, those eligible for the Medicaid Buy-in for Working People with Disabilities program or Medicaid’s Cancer Treatment programs.

  46. New York Medicaid Expansion and Eligibility (contd.) • Most MAGI enrollees will get an alternative benefit plan (ABP) benefit • Difference between the ABP and standard Medicaid is that the ABP does not include institutional long term care. • Applicants in need of LTSS are eligible for standard Medicaid as non-MAGI, so the impact of the ABP on low-income clients should not be significant. • Many direct service professionals may qualify for Medicaid under the expansion.

  47. Implications for DSPs?

  48. The Affordable Care Act Employer Responsibilities • Employers with 50+ full-time equivalent employees must provide adequate and affordable health care insurance or pay penalty • “Affordable” • Out-of-pocket premium for employee (single) coverage does not exceed 9.5% of family income or the plan pays, on average, 60% or more of the cost of covered services. • Delayed by one year

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